Abstract
A 71-yr-old male presented in the emergency room with a history of several days of fever, chills, nonproductive cough, weakness, anorexia, and generalized malaise. Significantly, his history included mitral and aortic valve replacement a year earlier. On physical examination, the patient's heart showed an irregular rhythm and the electrocardiogram suggested atrial fibrillation with rapid ventricular response. His white blood cell count was elevated at 17,600/mm 3 (normal 4,800 to 10,800); his platelet count was depleted at 36,000/mm 3 (normal 130,000 to 400,000). The initial emergency room impression was that of atrial fibrillation, thrombocytopenia, and leukocytosis. The patient was admitted for further evaluation for chronic congestive heart failure, with hypertension and possible upper respiratory infection. Suggested differential diagnoses included urinary tract infection, endocarditis, cholecystitis or ascending cholangitis, and/or sepsis of unknown origin. An echocardiogram did not suggest any superimposed vege-
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